Primary-care physicians can be important providers human
immunodeficiency virus (HIV)-prevention services to their patients.
In 1991, 15% of U.S. adults reported having been tested for HIV
antibody; of these, 55% reported their most recent HIV test had
been in a physician's office or a hospital (1). During 1992, CDC
and the Health Resources and Services Administration (HRSA)
commissioned a national survey to characterize the types of HIV
prevention services provided by primary-care physicians and
barriers to the provision of these services. This report summarizes
the results of the survey.

In October 1992, a questionnaire was mailed to 4011 *
primary-care physicians who were randomly selected from the
American Medical Association (AMA) Physician Masterfile, which
comprises all physicians in the United States. The sample was
stratified by location, race/ethnicity, and specialty. Two
categories of location were defined on the basis of the prevalence
of acquired immunodeficiency syndrome (AIDS) in metropolitan
statistical areas (MSAs): 1) physicians practicing in the 20 MSAs
with the highest prevalence and 2) those practicing in the
remaining MSAs. Physicians were asked about their risk assessment
of new patients; HIV counseling, testing, and treatment practices;
and basic understanding of and attitudes about HIV infection and
persons with HIV disease. The data were weighted to adjust for
unequal probabilities of selection and for the variability of
response rates among the strata.

Of the 3735 eligible ** physicians, 2545 (68%) responded; of
these, 802 were general/family practitioners; 360,
pediatrician/adolescent medicine physicians; 683,
obstetrician/gynecologists (OB/GYNs); and 700, general internal
medicine physicians. Of the 2545 respondents, 1931 (76%) were men.
Three hundred eighty (15%) were aged less than 35 years; 1042
(41%), 35-44 years; and 1123 (44%), greater than 44 years. Of 2496
respondents for whom primary practice was known, 1487 (60%) were
based in private, single-specialty practices; 442 (18%), in
private, multispecialty practices; 299 (12%), in hospitals, public
clinics, and community health centers; and 267 (11%), from academia
and other institutions. Six hundred two (24%) of the physicians
were located in areas with high prevalences of AIDS.

Almost all (94%) respondents indicated they "usually" or
"always" asked new adult (aged greater than or equal to 19 years)
patients about cigarette smoking; however, sexual history-taking
was less frequently reported (Table_1): 49% asked about
sexually
transmitted diseases (STDs), 31% about condom use, 27% about sexual
orientation, and 22% about number of sex partners. In comparison,
84% of all physicians asked new adolescent (aged 13-18 years)
patients about cigarette smoking, 56% about STDs, 52% about condom
use, 34% about number of sex partners, and 27% about sexual
orientation. One fourth (25%) of all physicians believed their
patients would be offended by questions about their sexual
behaviors.

The percentage of physicians who indicated they would "likely"
or "very likely" encourage HIV testing varied by patient risk
category (Table_2) and ranged from 95% (homosexual men with
multiple partners and injecting-drug users) to 40% (sexually active
adolescent patients).

Most physicians (66%) indicated that if HIV testing were
indicated for a patient, they would probably provide the test
counseling themselves. Factors that either "moderately" or
"strongly" influenced physicians to refer for counseling and
testing rather than provide it themselves were that counseling was
too time consuming (55%), information was insufficient to enable
counseling (45%), and they preferred anonymous testing for their
patients (42%). Most respondents indicated that their decision to
refer was not influenced by inadequate reimbursement (86%) or
discomfort with counseling (85%).

Ninety-two percent of physicians indicated that they would
counsel an HIV-positive patient to reduce the risk for transmitting
HIV. In addition, 76%-81% indicated they would counsel the patient
to notify sex partners, refer the patient to the local health
department for assistance with the notification, or both.

Of physicians in OB/GYN practices, 85% indicated they would
provide contraceptive services and 47% would provide prenatal care
to all women, regardless of their HIV status (Table_3). In
comparison, 73% would provide contraceptive services and 29% would
provide prenatal care to women with HIV.

Physicians who reported they would refer patients with HIV for
medical services indicated the primary reasons for referring were
their lack of experience with HIV (83%) and the availability of
other providers with more expertise in treating HIV infection
(94%). Overall, 68% of physicians indicated they believed they had
an obligation to take care of someone infected with HIV, and 87%
indicated that professional training could help "increase their
comfort in caring for AIDS patients."
Reported by: J Loft, PhD, W Marder, PhD, Abt Associates, Inc.,
Chicago. L Bresolin, PhD, R Rinaldi, PhD, American Medical
Association. Div of Medicine, Bureau of Health Professions, Health
Resources and Svcs Administration. National AIDS Information and
Education Program, Office of HIV/AIDS; Women's Health and Fertility
Br, Div of Reproductive Health, National Center for Chronic Disease
Prevention and Health Promotion; Div of Sexually Transmitted
Diseases and Human Immunodeficiency Virus Prevention, and
Behavioral Studies Section, Behavioral and Prevention Research Br,
Div of Sexually Transmitted Diseases and HIV Prevention, National
Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: Although primary-care physicians may contribute to
the prevention of HIV transmission by counseling patients who are
at risk, the findings in this report underscore the substantial
number of physicians who are missing opportunities to counsel
during encounters with patients. To more effectively use these
encounters as a means of prevention, physicians first must be
knowledgeable about HIV infection and its transmission (2). In
addition, they should be made aware of the importance of assessing
patients' risk for HIV infection and prepared to counsel patients,
based on their risk (3). Therefore, medical schools and
professional organizations should continue to emphasize HIV/AIDS
prevention and treatment as priorities in training new and
practicing physicians.

The findings in this report can assist in the development of
HIV prevention policies and programs. For example, the reluctance
of some physicians to assess the risky sex practices of patients
underscores the importance for public health agencies to assist
physicians in improving risk assessment and risk-reduction
counseling efforts for their patients and patients' partners. These
findings may be used by HRSA to improve training strategies and
programs for health-care professionals and AMA and other
professional organizations to develop training objectives for
primary-care physicians.

Finally, these findings can assist in efforts to achieve the
national health objectives for the year 2000 regarding HIV
prevention (4). These objectives include increasing to at least 80%
the proportion of persons with HIV infection who have been tested
(objective 18.8); increasing to at least 75% the proportion of
primary-care and mental health-care providers who provide
age-appropriate counseling on the prevention of HIV and other STDs
(objective 18.9); and increasing to at least 50% the proportion of
primary-care clinics who screen, diagnose, treat, counsel, and
provide (or refer for) partner notification services for HIV
infection and bacterial STDs (objective 18.13).

** Physicians who were not practicing in one of the primary-care
specialties, were practicing out of the country, retired, or
deceased were deemed ineligible.
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